4992 A.PPLICAANT TO FILL-IN INFORMATION WITHIN RED LINES —'USE BALL POINT PEN ONLY
T ✓ " §LILDING PROJECT IDENTI FICATIOIk@7 ey. PERMIT NUMBER;BUILDIN
APPLICATION PERMIT
ADDREss P "�`V7
ap . BUILDING — ELECTRICAL—PLUMBING —MECHANICAL
PLAN CHECK VALIDATION,
NAME TV. ELECTRIC PERMIT FEE
CONTRACTORS
NAME ' OUTLETS-SWITCHES-R ECEP '5.00/1.00
LIa NO LIGHTING FIXTURES .' 5.00/1.00
CONTRACTOR'E1
ADDRESS APPLIANCES-flESIDENTIAL 4.00
PHONEPANELS - 5.00 DATE OF APPLICATION
ARCHITECT 'PLAN CHECK FEE P.C.NO.
oR SIGNS '6.00
ENGINEER
' uc.NG. SIGNS TRANS. 3.00
ADDRESS ErvG. SPECIALCIRCUIT - 5.00 PERMIT VALIDATION
iiP TEMP.METER OR POLE INS. 15.00 �')
APPLI MOTORS SEE FEE SCH. Xt
ADDRESS
ss - -
q •- SERVICE CHANGE 10.00
09 _ LICENSED CONTRACTORS DECLARATION
a u w 1 hereby affirm that I am licensed under provisions of Chapter 9 - ATE
(commencing with Section 7000)ofDivlsloo3 of the Business and rn¢ n BLDG.- ELECT. PLG. MECH.
r n z Professions Code,and my license is in full force and effect.
0 m
141
o G License Class Lia.Number - -
Data Contractor - a
E BUILDING PERMIT
a Ono affirm
that I am DERexempt
DECLARATION PH MATION
X '1-
ca I hereby affvm that.l int exempt from the Contractor's License MISC.'— - REFER TO ORD 1
HLse J . 'Law for the following reason.(Sec.7031.5,Business Professions PERMIT ISSUANCE 6.00
Code:Any city or county which requires a permit to construct,alter, QO�
QQ Q 0 'Improve,demolish,Or repair any structure.prior ID Its Issuance,also ELEC.CONTE. + CLIC.NO. ELEG �- - •.
'y a
O u requires the applicant for Seth permit to(ie a signed statement that - TOTAL - PERMIT TO
he is licensed pursuant to the provisions of the Contractor's License
.HiQ. La. Chapter9(commencing with Section 7000)of Division 3 of the ��l/,T2-4J0 K, Y�fHJ
14 D Business and Professions Code).,'that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
or H $' 'the basis for the alleged exemption.Any violation of Section 7031.5 STORIES ,TYPE CONSTR.
by any applicant for a permit subjects the applicant toacivilpenalty ALTER-DRAIN -WATER (EA.) 41.00
-
•of not more than five hundred dollars(55001.)', . . '
❑' I,as owner of the property,or my employees with wages as BACK F LOW PROTECT:DEVICE. 2.00 . OCCGROUP EES.uw TS
their sole compensation,will do the work,and the structure is not . _
intended or offered for sale (Sec. 7044, Business and Professions - DRAINS-FLOOR,ROOF,AREA,COND. 4,00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 ..SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve- GAS q;00
mems are not intended or offered for Sale.If,however,the building ,
or improvement is sold within one year of completion'tire owner- GAS-EA'.SVSTEM-OVER 4(EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or int- RES:! IND CON U PB Omer
Prov for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
I,as owner of the property,am exclusively contracting with - ❑ _❑ ❑ ❑ ❑
licensed can tractors Yo,construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL No.
and Professions Code:The Contractor's License Law does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00 t ,
contracts.for such projects with a contractons)licensed pursuant to
the Contractor's License Law.. SEWER-SANITARY-STORM EA.200ft/8.00 TRACTNO. PARCELNO.
❑ lam exempt under Sec. ,B.&P:C.for this
WATER HEATER WIVENT - 4.00 -
0
Uate Owner WATER SYSTEM 4.00 ACC.DATE ACG FILE NO.
• 'WORKERS'COMPElsSATION'DECLARATION WATER TREATING EQUIP.' . 4.00,
1 hereby affirm that I have a certificate of consent to self-insure,
or a certificate of Workers'Compensation Insurance,or a certified- ' ZONING ENG.SITE NO.
- copy thereof(Sec.3800,Lab C.). -
Policy No. Company
Q ❑ Certifiedc.pyishereby'famished- FIRE SPRINK ENERGY T-24
Z
❑ Certified copy'is filed with tlte.city inspection division.' MISC.- REFER TO ORD.
O Applicant . Y [:] N❑ Y [:] NE] '
p: rn - PERMIT ISSUANCE 6.00 FLOOOZONE A.L.U,C.
LU CIiRTIPICCOM E EXEMPTION FROM WORKERS'
W >� COMPENSATION INSURANCE PLG.CONTR. uc.NO. PLc. - "'
0. Cl (This section need not be completed if the permit is In,one TOTAL - �Y❑, N❑ V ❑ N❑.
hundred dollars($100)ov IessJ
U O 1 certify that in the performance of the work for which this per- OTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,I shall not employ any person in any tanner so as to
U become subject to the Workers'Compensation Laws of California.
W Date' Applicant BUILDING �t� -
a ALTER OR ADD TO MECH: 4.00 V
} N NOTICF. TO APPLICANT If,after making this Certificate lix.
F Z
empEon,vision you should become subject m the Workers'Compensasa tion APPLIANCE 4.00 .PLAN-CHECK,
provisions of the Labor Cit shallhalloo most forthwith comply with FEE -
such provisions or this permit hallbe deemed revoke.). AIR HANDLING UNIT(TO 10,000QF.M.) 3.00 -
CONSTRUCTION LENDING"AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 5.00 SEISMIC FEE` xJV
I hereby affirm that theta is a construction lending agency for - EXHAUST HOOD(WITH DUCT) 2.00
the peiformance of the work for which this permit is issued(Sec. - - MICROFILM
3097,Cie.C.). f HEATING UNIT(TO'100,000 B.T.U.) 4.00
Lender's Name - HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC ' -
Lender's Address
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00 ,
information is correct 1 agree tocomply,with all clty'and county PLUMBING -
ordinances and•state'laws.relatrng m-building.ocnstruction, and B0'LER F_COMPI3 H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives of this'efy to enter upon the BOILER-COMPIOver 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) .gree to save, indemnity and keep harmless the City of MISC.-= REFER TO ORD. .
Cupertino against liab" ents, costs and expenses which CONST.TAX
may in any way a rue again id_ City,in consequence of the - 'PERMIT ISSUANCE - 3.00 �•'•
t. grn ,f this per —� O MECH.CONT. LIC.NO. TOTAL, TOTAL
L J
S [are ol'Ap a t onhactor F M
- - ' OFFICE COPY
CITY OF CUPERTINO INSPEMON RECORD
(OFFICE COPY)
ADDRESS LOT NO—
OWNER
ao72 c
PERMIT ISSUED DATE ELECTRICAL DATE INSP.
u�ildin
Erica
Plumbing Power Pole
mechanica r oun
em1 as ec u Wiring
o ar Walis
Fire Sprinkler m _
bi ixF^tures nt xt
Motors
Misc. Groundui
e ower
Uther
FINAL INSPECTIONS DATE INSP. Not Approved
Gas
Electric
Plumbing PLUMBING DATE INSP.
Mee Tianica �nZ—. /l-aG P`
Ian Backflow
JO - Underground
. . .
ra ung Undertloor
Planningartier
ire t. ou i oup ete
Health t. bolar Rough
m in aterio_
t er in . rain
oDrain
as
,Other
BUILDING DATE INS-P. of rove
Pad Certification
oun =tion ELECTRICAL DATE INSP.
re- unite
Slab-Membrane Underfloor S.M.
Eond Beam Ducts & Insulation -T(
Underfloor oor it ers Fire Dampers
Floor Steel ire ace
ie owns Grease Duct i; Hood
is ramsi�a Flour Shaft
eismec racin A ' d – _yN Condensate sate rain
Walls- ane s Equipment Anchorage
Frame ues 4 Comb. Air
adrL—at Uther
oars nt xt. of rove
Firewa s
Other
Not rove